Provider Demographics
NPI:1902813330
Name:LIMTIACO, LISA M (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:LIMTIACO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16542 VENTURA BLVD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2005
Mailing Address - Country:US
Mailing Address - Phone:650-799-4201
Mailing Address - Fax:866-739-7720
Practice Address - Street 1:16542 VENTURA BLVD
Practice Address - Street 2:SUITE 115
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2005
Practice Address - Country:US
Practice Address - Phone:650-799-4201
Practice Address - Fax:866-739-7720
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2012-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10368T152WC0802X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0103682Medicare ID - Type Unspecified